Section: NURS 6512N Week 5 Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

• Denies past surgical intervention. Sexual/Reproductive History: Personal/Social History: • Third grade • Attendance record: out for two weeks last year due to pneumonia • Lives with mother and father, grandmother provides care while parents’ work. • English spoken at home primarily. But some Spanish used. Immunization History: • No influenza vaccine in the past 12 months • Hep B- 3 dose series completed at 6 months. • Hep A – 2 dose series completed at 15 months. • Pneumococal – 4 dose series completed at 15 months. • DTap – 5 dose series completed at 6years. • MMR – 2 dose series completed at 6 years. • Varicella – 2 dose series completed at 6 years. • Polio – 4 dose series completed at 6 years. Significant Family History: • Mother: Type 2 diabetes, HTN, Hypercholesterolemia, spinal stenosis, obesity • Father: smoker, HTN, Hypercholesterolemia, asthma as a child • Maternal grandmother: Type 2 diabetes, HTN • Maternal grandfather: Smoker, eczema • Paternal Grandmother: died in car accident at 52 years old • Paternal grandfather: No known history Review of Systems:. General: Patient stated being tired due to poor sleep pattern. Patient indicated recent weight gain, but no change in his appetite. HEENT: • Head: Denies headache • Eyes: Denies vision problem, watery eye, eye redness, eye pain. • Ears: Patient complains of right ear pain. Reports history of ear infection. Patient reports good hearing. Denies ear popping, or crackling, ear tubes, or surgery, • Nose: Reports nose is often runny. Pt states clear, thin discharge. Denies nose bleeds. Denies sinus pain. • Throat: Denies any mouth or gum problems. Reports having little difficulty swallowing. Reports sore throat